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18 Articles in Volume 11, Issue #9
Pain and Sleep: A Delicate Balance
Management of Insomnia: Considerations For Patients With Chronic Pain
PPM Editorial Board Outlines Management Strategies for Chronic Pain Patients With Insomnia
Attention Deficit Hyperactivity Disorder And Patients With Pain
Dry Needling Offers Relief From Chronic Low Back Pain
Etiology of Chronic Pain and Mental Illness: How To Assess Both
Temporomandibular Disorder: Examining the Cause And Treatments
Highlights From PAINWeek 2011
Is Your Patient Using Heroin?
Medications For Low Back Pain
Nonpharmacologic Treatments for Patients With Sleep Disorders and Pain
Man With Constant, Daily Headache Pain, Photophobia, Phonophobia, and Nausea
Successful Nonoperative Treatment of Persistently Painful Knees Following Total Knee Arthroplasty—A Case Series
Insomnia in Chronic Pain Patients
What Is Going Wrong With Research? Finding the Right Answer
Testing Positive for Marijuana in Urine
Hydrocodone, Carisoprodol, and Alprazolam—A Most Lethal Combination
Pro-inflammatory Diet

Attention Deficit Hyperactivity Disorder And Patients With Pain

A growing number of patients with chronic pain are presenting with ADHD. Clinicians need to understand how the disorder is diagnosed in adults, as well as how to balance various medications required to treat both ADHD and pain.

Along with anxiety and depression, attention deficit hyperactivity disorder (ADHD) is a common comorbidity among patients with chronic pain. Although most commonly diagnosed in childhood, ADHD is seen in approximately 4.8% of adults.1

ADHD has become a well-recognized and validated syndrome, known for the havoc it can create in patients’ lives. The public is increasingly aware of ADHD, and more of our patients arrive at the clinic with that diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for ADHD will be amended in the upcoming DSM-V; the current criteria relate primarily to children and adolescents and are not entirely applicable to an adult population. Because more patients carry the diagnosis and are on ADHD medications (primarily stimulants), it is important for pain physicians to be aware of the consequences of the disorder. In addition, it is helpful to be aware of interactions between ADHD and pain medications.

Diagnosis of ADHD in Adults
The diagnosis of ADHD includes the patient’s history along with corroborating evidence: educational records and history, input from family or significant other, and so forth. In my experience, most patients who carry the diagnosis of ADHD from childhood have been correctly diagnosed; although there is occasional overdiagnosis of ADHD, underdiagnosis remains more prevalent.

The DSM-IV criteria for the diagnosis of ADHD require that the symptoms have lasted for at least 6 months.2 As noted, the current criteria do not always reflect the adult patient with ADHD. For example, the three primary features of ADHD (attention, hyperactivity, and impulsivity) change over time. Many children and adolescents “lose” the “H” (hyperactive) portion of ADHD as they approach adulthood, and present as the inattentive type. Therefore, using hyperactivity as a measure of ADHD may not be valid in adults.

In addition, ADHD adversely affects adults in their family and work lives; these effects are not addressed by the current criteria. The age of onset, usually listed as before 7 years of age in the DSM-IV, may not be accurate when assessing adults, and adults’ recall of the exact age of onset is often inaccurate. In the DSM-V, it is possible that the age of onset criterion for adult ADHD may either be dropped or amended to state that symptoms must have begun by age 15 or so.

In children, input from parents and teachers is crucial. In adults, we often use patient recall for assessment, in addition to speaking with others who know the person well. There are pitfalls in assessing adults; for example, we must not compare the patient with a high-functioning, high-IQ peer group, but rather with average individuals. In addition, particularly in college students, the desire to excel on examinations or improve scores does not qualify as a diagnosis of ADHD.

Mood disorders may cause an attention/concentration problem in adults, leading to an inappropriate diagnosis of ADHD. However, most patients with ADHD do have associated psychiatric comorbidities, such as anxiety or depression. Many individuals who fit on the bipolar spectrum can have concurrent ADHD. It is important to assess patients for all of these conditions.

One objective test that we have found useful is the Adult Self-Report Scale (ASRS),3 which is an 18-item questionnaire. The first nine questions relate to attention, the remaining nine to hyperactivity. Using the first nine questions gives the clinician an easy screen for ADHD and requires only minutes to administer. The attention portion of the ASRS gives a score of 0 to 36, with 36 being the most severe. This scale or similar ones, along with the clinical and educational histories, helps to determine the diagnosis.

An important question to ask the patient is, “How difficult is it for you to do boring tasks?” People with ADHD have great difficulty with boring material. To aid the diagnosis, I often have the patient read books or other materials on adult ADHD so that they can provide better-informed input into the diagnosis.

ADHD and Impairment
Adult patients with ADHD often are impaired in several categories. They may have done poorly in school, leading to problems with their work and career. Home life is adversely affected, with problems fulfilling daily responsibilities. Relationships are negatively affected by ADHD, and family life often falls apart as a result. The severity of childhood/adolescent ADHD is an accurate predictor of impairment as an adult. Young children who are constantly restless and cannot wait their turn in line, for example, often show more impairment as young adults. ADHD increases the likelihood of driving accidents and also of drug or alcohol abuse. It is probably not true that ADHD allows one to excel in certain areas; the evidence speaks more for impairment than for any positive outcome for those with ADHD, particularly if it is not treated.

The associated psychiatric comorbidities add to impairment, particularly if they are not treated. These include anxiety, depression, bipolar depression, and substance abuse.

The evidence is strong for treating ADHD. Compared with treated patients, those who remain untreated are at greater risk, at age 20 to 25, for drug abuse, accidents, joblessness, and jail. The clinical stakes for underrecognizing and undertreating ADHD are enormous. If impulsivity does not improve by the early 20s, it is a poor prognostic indicator for how the patient will do over time.

ADHD and the Patient With Pain
ADHD complicates the lives of patients with pain. The patient struggles with functional impairment due to pain, and ADHD adds to this dysfunction. Education often suffers because of pain; students take longer to complete their degree, and the addition of the negative impact of ADHD can make completion impossible. Family life is adversely affected, as spouses may tire of the burden of pain complaints, along with the various ADHD symptoms. Chronic pain often leads to performance issues at work or joblessness; ADHD only accentuates this problem. It is not uncommon for patients with chronic pain and ADHD, in combination with anxiety and depression, to be underfunctioning in a number of areas.

ADHD Medications
“First-line” medications for ADHD are stimulants.4-6 The most commonly used stimulants include methylphenidate (Concerta, Ritalin, others), dextroamphetamine (Dexedrine, others), amphetamine and dextroamphetamine (Adderall), and lisdexamfetamine (Vyvanse). The longer-acting forms are Adderall XR, Vyvanse, Ritalin LA, Focalin XR, Daytrana, and Concerta. Side effects of these agents include, among others, anxiety, insomnia, tachycardia, and, occasionally, increased headache. The stimulants have mild analgesic effects and in some patients may be an adjunct for the pain. In addition, some patients with depression find that the stimulants act as an adjunct for the depression, whereas in others they may actually exacerbate depression. Fatigue is a common comorbidity encountered in patients with pain, and stimulants may help their energy level during the day. In addition, the anorexiant effects are beneficial for some patients with pain, as obesity and weight gain are commonly encountered among this population.

The stimulants may improve attention, energy level, pain, and depression, as well as decrease appetite. However, many patients cannot tolerate the adverse effects of stimulants. In addition, patients with pain are usually on various medications, with possible interactions. For instance, these patients often take antidepressants, with resulting tachycardia when combined with stimulants. When patients with pain are taking daily opioids, adding a stimulant contributes another potentially addicting medication. Fortunately, addiction to stimulants among adults with ADHD is uncommon.

When stimulants are not appropriate or are not tolerated, various “second-line” medications can be tried for ADHD. The α2-adrenergic agonists (guanfacine ER [Intuniv], clonidine [Kapvay]) are primarily used in children and adolescents. Various antidepressants have been successfully used for ADHD. These include the older tricyclics (desipramine, nortriptyline), as well as bupropion. These may be appropriate with concurrent anxiety or depression. Atomoxetine (Strattera), a selective norepinephrine reuptake inhibitor, is used as a second-line medication for ADHD and is very similar to the tricyclic desipramine, which also increases norepinephrine. Although these medications are not as effective as the stimulants, they offer several benefits, including the advantage of being nonaddictive, and, when used as once-daily medications, being long acting.

Nonmedication Treatments
In addition to medications, we often refer patients to psychotherapy. Although therapy does not improve attention itself, the patient benefits in a number of ways. These include receiving help with associated anxiety/depression, family life, relationships, organization, and work life. A good therapist who is acquainted with pain and ADHD can play a crucial role in improving a patient’s functioning and quality of life.

It is important to work on sleep issues and diet. In addition, as with almost all patients, we supplement with at least 2,000 units of vitamin D3. We stress the role of exercise, advising patients to try to build up to 20 to 30 minutes daily on average.

Conclusion
ADHD is commonly encountered, and is seen in 4.8% of adults. The various symptoms complicate the lives of patients with pain. The clinical stakes for not recognizing ADHD are enormous; patients often underperform at work, have poor family relationships, and are at increased risk for substance abuse. Treatment with medications, primarily stimulants, improves quality of life and functioning. In addition, psychotherapy plays a role, as does stressing the role of sleep, nutrition, and exercise.

 

Last updated on: December 15, 2011
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